The Impact of New Communication Tools By Lindsey GetzFor The RecordVol. 21 No. 23 P. 20

A look at the way e-mail, text messaging, and observations of daily living are changing the way health information is exchanged.

The way we communicate is rapidly evolving, and it’s no different in the healthcare world. Though it may be a little behind other industries, which have been using new forms of communication for awhile, healthcare is beginning to embrace new communication patterns. Three in particular—e-mail, text messaging, and observations of daily living (ODLs)—have risen to the forefront to give caregivers and consumers a variety of new options when it comes to exchanging information.

Effective E-Mailing
What’s really been forging the way for new communication opportunities in healthcare is the mobile device. SNL Kagan, a Virginia-based research company, released a 2007 report in which it predicted that more than 100% of the U.S. population would have mobile phones by 2013 as a result of individual users owning multiple devices. “A mobile device enables the user to communicate anywhere, anytime, and any place to any person,” says Claudia Tessier, RHIA, president of mHealth Initiative, Inc. “Many individuals that have cell phones don’t even use the voice capabilities as the primary function anymore. They use texting or e-mail. And what that means within the healthcare industry is that patients can have quick and easy contact with their physicians to do something like request an appointment.”

Physicians are using e-mail for more than scheduling. For some, it has been an effective way to communicate information, possibly even in place of a face-to-face visit. “E-mail may be a way to bypass that introductory visit and get to the heart of the issue more quickly and maybe even more effectively,” notes Tessier. “If a patient is having certain signs and symptoms, perhaps they need to have some tests done before they go into their physician’s office. With e-mail, they can discuss the symptoms with their doctor, have the tests ordered, and then go in for the appointment with test results in hand. It saves them from making an unnecessary visit and saves the doctor time, too.”

What has held some physicians back from going this route has been their concern with meeting HIPAA requirements for security and privacy and, more recently, the increased emphasis on enforcement as a result of the American Recovery and Reinvestment and HITECH acts. However, software solutions could help eliminate this issue.

MaxMD has created one such solution. The company’s .mdEmail products provide the healthcare market with a secure, top-level domain and an encrypted, interoperable platform that complies with all HIPAA regulations. “Basic e-mail is not suitable for healthcare because it doesn’t protect sensitive information,” explains CEO Scott Finlay. “HIPAA prescribes that any sensitive data sent over the Internet must be encrypted. Our product puts a firewall around our top-level domain, and all communication happens safely behind that firewall. It allows for the direct transfer of any information—from practice to patient, from practice to peer, or from practice to a business associate. [It’s] never exposed to the Internet. This gives healthcare an opportunity to communicate using e-mail like every other industry has already been doing.”

Marcy Zwelling, MD, who is in private practice in Los Alamitos, Calif., is a believer in e-mail’s productivity. “Why should a patient have to get in their car and drive to an office and sit in a waiting room for two hours to ask a few questions that could’ve been asked through e-mail?” she asks. “If a patient tells me they feel awful and have a fever, it doesn’t make sense to make them get out of bed. Instead, we discuss their symptoms and I tell them what to do through e-mail. Then I follow up the next morning.” Zwelling also sends e-mail blasts and newsletters to her patients to maintain more regular communication.

Finlay says e-mail can also be used for previsit and postvisit instructions and sharing forms and other paperwork that need to be filled out, adding that this form of communication is likely more effective than exchanging information in person. “It’s been estimated that the average patient forgets 80% of what they’ve been told once they leave their physician’s office, especially if you find out bad news,” he notes. “You may be in shock and not really listening to what the doctor is saying. You get home and realize you don’t know what to do next.”

In the past, many physician offices have used faxing to disseminate information to patients and other offices, but new HIPAA laws may make that option obsolete. “We recently received a memo from our attorney stating that any communication that is not fully encryption secure will no longer be acceptable, which includes faxing, a primary means of sharing data,” says Beth Crowder, executive director of United Physicians, a physician organization in Charleston, S.C., that facilitates participation in healthcare plans and provides services promoting quality and efficiency in the practice and business of healthcare.

For a physician practice, Crowder says using encrypted e-mail is more time efficient and cost-effective than faxing or phoning. The integration of a secure program allows for communication among practices and vendors dealing with protected health information. “Because of the ease and time-saving qualities of e-mail, .md physicians now have more opportunities to communicate with other physicians and patients,” she says. “It means fewer steps than paper or phone, so they are more apt to integrate this into their workflow—not to mention the fact that it helps them become more compliant with HIPAA and the HITECH Act. We believe over time physicians will be using encrypted e-mail much more than they have in the past.”

Crowder adds that it’s important for the transition to e-mail communication to be as easy and unobtrusive as possible. “E-mail is a system with which everyone is familiar, and for physicians, who are already extremely busy, this is critical for ease of adoption. It removes the ‘hassle factor,’ which out of necessity comes with many new technologies,” she says.

In addition, adds Finlay, the cost savings are enticing. “We had one doctor tell us he spends $2,000 a year on postage, sending out information to patients,” says Finlay. “Since we charge $450, he can save over $1,500 by going paperless and handling all of that correspondence via e-mail.”

Texting, Too
Text messaging (more technically known as short message service, or SMS) is another function of mobile devices that is changing the face of healthcare communication. A text message, which allows the user to send a short message of up to 160 characters to a mobile device, creates numerous possibilities in the healthcare field. Hospitals and physician offices can send out appointment reminders, give notification that lab results are ready, or send reminders about annual exams such as mammograms or immunizations. “There are institutions and organizations that are currently looking at whether patients prefer this kind of communication for information such as reminders as opposed to getting them over the phone or through the mail,” says Tessier. “Using text messaging for reminders can significantly reduce costs for the institution, and some patients themselves are pushing for it.”

Recently, the Centers for Disease Control and Prevention (CDC) has taken an active interest in the possibilities that text messaging allow for in relaying health information. “Texting is something that can reach a lot of people, and it’s become a high priority for us this year,” says Janice R. Nall, director of the CDC’s e-health marketing division. “We have a number of projects currently going on in this sphere.”

According to Nall, there are several reasons for the CDC’s interest in utilizing mobile devices, including the fact that people tend to always have them available and text messaging allows for information to get out rapidly, even when other forms of communication may not be available. “In an emergency situation, people may not have access to the Internet or mobile phone calls, but they could still have access to mobile texts,” she says. “When Hurricane Ike struck, calls and e-mails were not getting through, but mobile texts were. So we were still able to send out text messages with important information, such as how much bleach to put in water to purify it. It’s something that has the capability of being potentially lifesaving, of being the only way to get a message out to the public in an emergency.”

The CDC has several text messaging programs, including an H1N1-related project, and pilots in the works that allow users to sign up to receive information briefs. (The public can join the program by texting HEALTH to 87000.) The CDC will take a look at the data received from these programs to determine their effectiveness, as well as important demographic information on the users, which will help make decisions as it addresses future messaging possibilities.

One bit of insight has been gleaned thus far: Nall says it can be challenging to write an important health message in only 160 characters, which includes spacing and punctuation. “We’ve learned that health messages need to be fact based and concrete and should break down the information into the most helpful objectives,” she says. “For the flu, we don’t just say, ‘Go get your vaccination,’ but instead we provide the age ranges for who should be getting the vaccination and in what form. All of the information out there can be confusing, so we focus on breaking it down.”

Like e-mail, security risks do need to be taken into consideration when communicating via text messaging. “We typically work with a mobile vendor that has expertise in this area,” says Nall. “They are experts in their field and, since there are a lot of security requirements to deal with, it helps to have that support.”

Getting Personal: ODLs
Though quite different than technology-based forms of communication such as e-mail and text messaging, ODLs are also an important new data collection method. This patient-centered practice gathers information on activities and experiences such as diet, exercise, sleep patterns, and adherence to medication regimens in addition to standard data recordings. People with diabetes, for instance, may record their own blood glucose levels but, in addition to noting the levels and the times they were taken, they would also note other data such as what they’d eaten that day or perhaps even the amount of exercise they endured—additional experiences that likely affected the readings that were obtained. The adoption of ODLs for data gathering is changing what kind of information is considered pertinent for a health record—and, more importantly, who is gathering that information. It’s also another step toward the development of reliable and accurate PHRs, making them a more trusted source of patient data.

“We’re interested in how these ODLs are able to track data in a way that might help enhance an individual’s ability to manage complex healthcare problems,” says Patricia Flatley Brennan, RN, PhD, FAAN, a professor of nursing and industrial engineering at the University of Wisconsin-Madison and the director of Project HealthDesign, a national program of the Robert Wood Johnson Foundation designed to stimulate innovation in personal HIT. “Some of the experiences that a patient describes for us might actually help the patient and the physician not only better understand and manage an illness but live a healthier life overall.”

Brennan says ODLs can also be valuable for assessing the best treatment options. “As healthcare gets even more complex, the answer to ‘what is the correct treatment?’ for a particular patient may become less obvious,” she says. “The answer is the one that fits best into their life and has the least management difficulties. But in order to know what that is, it’s important for an individual to be able to have a way to track what’s occurring in their everyday life compared to what’s happening with their clinical treatment. The result could have a significant benefit in ensuring effective care is given.”

Making the Transition
Taking advantage of new ways to exchange healthcare information has several benefits for providers. For one, they can help form a hub that connects the entire medical community, something that was previously missing, says Crowder. “When you’re looking at independent physicians practicing in their communities, you realize that there are a lot of practices caring for the same patients but no hub to facilitate communication among them,” she says. “Although large medical groups and hospitals are networked internally, we need a way for all medical providers within a community to send data securely. That’s where something like an encrypted e-mail platform is really going to work best. It is a form of connecting communication that will pull everyone together.”

While it may seem challenging to begin adopting these tools, the transformation seems to be gaining steam. “Healthcare is trying to get caught up to everyone else at supersonic speed,” says Crowder. “The way doctors run their business, technology has not typically been a main component as is standard within other industries. But we are now attempting to make a big leap forward into technology that improves the cost and quality of care as well as it protects the information associated with the care. This change has become a necessity.”